OPINION | Covid-19 - A rejoinder: the case for a tailored approach

It would be remiss, if not perilous, to act solely on the Covid-19 WHO guidelines in a country like South Africa, says the writer. (Getty Images)
It would be remiss, if not perilous, to act solely on the Covid-19 WHO guidelines in a country like South Africa, says the writer. (Getty Images)

The nationwide lockdown does a lot of good in its effort to help flatten the curve, and preventing further stress of an already stressed healthcare system, but it does have unintended consequences, writes Hloni Bookholane.

At the end of my medical degree at the University of Cape Town, my motivation in becoming a doctor was to develop a deeper understanding of factors influencing people's health - be it social, economic, or psychological - and why people get sick.

I learnt through my involvement in research projects that there exists a joint relationship between clinical practice, public health research and health policy.

From my clinical practice I gained confidence in the application of recommendations informed by research; and in research I was excited by how newly generated evidence informed clinical practice.

Neither alone was enough for me.

Following a 14-month application process and 6-months of internship at Groote Schuur Hospital, I was awarded a Fulbright Scholarship to pursue a Master of Public Health (MPH) at Johns Hopkins University in the US. 

I am currently in the final term of my Masters and it has been an interesting past few weeks; terrifying as much as it has been fascinating to be a participant and an observer in this global crisis.

I have volunteered a couple of times at the Johns Hopkins Medicine Unified Command Center which forms part of the Incident Command Center.

This centre is housed inside the Johns Hopkins Hospital and is, in my opinion, akin to the White House Situation Room.

My role as a volunteer is to triage, direct and re-direct phone calls in the call centre.

Though this is a different role than I am used to, what I have learnt as a result was summed perfectly by Dr. Esther “STAY AT HOME” Choo in a Twitter thread.

The front lines are staffed not only by doctors and nurses, but essential employees in administration, health and rehabilitation, information technology, laboratories, the pharmacy, and many others.

These components are that which armour the frontlines.

However, the front lines are formed differently between countries and within them.

In South Africa – one of the world’s most unequal societies with a Gini index of 63 - there are disparities which speak to a need for a different front line formation and application of interventions.

The implementation of an intervention package which is working in a country with less socio-economic imbalance ought to be done with consideration and caution in another.

The complex reality is that patients do not have their medical problems in isolation; their medical problems are in the context of their daily lives that are influenced to varying degrees by social, economic and psychological factors.

As such, Covid-19 infections and the interventions thereto exist not in a vacuum, but in these contexts.

Therefore, there is something to be said that a one size fits all approach won’t be the panacea to addressing the spread of Covid-19 in SA, but rather an approach amenable to adaptations if and when necessary.  

When the West Africa Ebola response was criticised, it was made clear that the classic "outbreak control" interventions would not suffice.

The implementation of said interventions depended on established and functioning health system infrastructure, all of which were limited.

The World Health Organization (WHO) intervention package was not customised as it ought to have been in dealing with the Ebola outbreak.

The same has been said in relation to the global pandemic we find ourselves in where certain interventions like social distancing have been critiqued as mindless, and privileges only a few can afford.  

It would be remiss, if not perilous, to act solely on the Covid-19 WHO guidelines in a country like South Africa where socio-economic stratification is omnipresent.

The announcement of the 21-day nationwide lockdown by a sanguine President Ramaphosa was well received by all and sundry in the country.

The unity and patriotism I noticed on my social media timelines was comparable to that which followed our 2019 Rugby World Cup victory.

But this unity and pride was balanced with the unavoidable reality that most people would not be able to do so.  

When the focus only is on one part of a narrative, we get a myopic, limited lens through which we view and do things.

The nationwide lockdown does a lot of good in its effort to help flatten the curve, and preventing further stress of an already stressed healthcare system.

However, it does have unintended consequences.

For example, the informal sector which provides employment to many South Africans, helps to keep households above the poverty line.

Without the informal economy, many of these South Africans face increased risk of Covid-19 and an exacerbation of pre-existing conditions, among many other socio-economic implications.

Without money for food, childhood hunger and malnutrition might be further exacerbated; many people will be unable to take their post-prandial prescription medication, and it is this combination of problems which highlights the unique set of competing interests in many low-middle income countries. 

If we are to assume a similar clinical course of Covid-19 infection as in other countries, it is true that many elderly people will die from Covid-19 in South Africa.

However, many others - old and young - may also die as a result of the measures put in place to address it.

That being said, as this pandemic evolves and spreads the world over, it would be prudent to consider national policies in context, and adapt them as necessary.

This ought to be done without fear or favour of criticisms which are often far removed, and only academically acquainted with these unique contexts.  

Finally, South Africa has an accomplished network of academics, clinicians, and scientists who are part of a global community of thinkers, with an acute awareness of the South African context.

As the country forges ahead in its effort to taper the course of Covid-19, drawing on the expertise it has to adjust and adapt international guidelines - as appropriate - will be critical in balancing the competing interests which exist in our country, like many others across Africa.  

- Hloni Bookholane is a medical doctor from South Africa, a Fulbright Scholar, and a Master of Public Health (MPH) student at the Johns Hopkins Bloomberg School of Public Health. Twitter @cuppahloni  

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